Inquest into the Death of TPL (a child Subject to a Suppression Order)

Inquest into the Death of TPL (a child) (Subject to a Suppression Order)

Delivered on :11 April 2016

Delivered at : Perth

Finding of : Coroner Linton

Recommendations :N/A

Orders/Rules : N/A

Suppression Order : Yes

The name of the deceased and any identifying information are suppressed from publication. The deceased is to be referred to as TPL (a child)

Summary : The deceased was a healthy six month old infant at the time of his death. On the morning of 8 January 2013 he was involved in a near drowning incident in a shower at his family’s home. Although he was resuscitated and given optimal medical care, he had sustained an unsurvivable hypoxic brain injury and died three days later.

The inquest focused primarily on the use of the baby “Bumbo” chair in the shower while unsupervised.

The deceased’s parents had purchased the Bumbo seat new from a retail store. The deceased had begun using the seat from approximately four months of age, usually in the living room when watching television and when showering in the morning. The seat is designed to support babies to sit upright unassisted and is marketed as suitable for babies as soon as they can support their heads unaided.

The Bumbo seat instructions for safe use in the manual include a warning to never use the Bumbo seat in or near water to avoid drowning. The seat purchased by the deceased’s parent had a warning sign printed on the rear of the seat. Despite the instructions against use in water and the presence of the warning sign, the deceased’s mother states that she was unaware that the Bumbo seat was not designed for use in water.

On 8 January 2013 the deceased woke at 6:00 am and seemed his normal happy self. The deceased’s mother began to pack an overnight bag for the deceased as he was going to stay with his grandmother overnight. The deceased’s mother took him into the bathroom and sat him in the Bumbo chair, which was in the usual position within the shower recess. The deceased’s mother turned the shower on, and then left the deceased alone in the shower, with the shower door slightly open. The deceased’s mother went into the toilet which was next door to the bathroom. She could not see into the bathroom or see the deceased from the toilet.

When the deceased’s mother left the toilet she went into the living room to continue to pack the deceased’s overnight bag. It is estimated that the deceased was left alone in the shower for at least 7 minutes. As the deceased’s mother entered the bathroom she noticed the deceased floating face down, submerged in a quantity of water. The Bumbo seat was no longer in its original place but was submerged in water and positioned over the top of the shower plughole. It appeared to be suctioned on to the drain hole.

The deceased’s mother immediately pulled the deceased from the water and ran with the deceased to a neighbour’s house for help. While the neighbour performed CPR the deceased’s mother rang for an ambulance. Ambulance officers arrived and found no sign of cardiac activity with pupils fixed and dilated. The deceased was taken to the Joondalup Health Campus. On arrival at the hospital the deceased still showed no cardiac rhythm although pulseless electrical activity was detected. The deceased was placed on a ventilator and transferred to the paediatric intensive care unit at Princess Margaret Hospital. The clinical diagnosis was that the deceased had sustained a severe hypoxic and/or ischaemic injury to his brain and that the prognosis was likely to be poor and most likely not survivable.

On 9 January 2013 the deceased developed some seizures and following a review a family meeting which was held with consultants who explained that the deceased suffered a catastrophic neurological event. On the afternoon of 10 January 2013 the deceased was extubated and given morphine for pain relief. He died on 11 January 2013.

The Coroner noted that this tragic death highlighted the importance for parents to remain vigilant whenever their children are near water, whether it is at home or elsewhere.

The Coroner found the deceased died on 11 January 2013 as a result of bronchopneumonia and hypoxic brain injury following immersion (near drowning) and death was by way of accident.